Prescribing Issues and Concordance

"We are heading towards Pharmageddon" - Paul Flynn, MP for Newport West.¹

Drug treatment is the most common form of treatment in primary care, with an estimated 60% to 75% of patients receiving a prescription on consulting their GP. Although prescribing is an important part of primary care, it has frequently been described as unnecessary and wasteful. Repeat prescribing has been highlighted as a particular problem area; 66% of prescriptions issued are repeats where no face-to-face contact between patient and GP occurs. The need for greater co-operation between community pharmacists and GPs to rationalise the use of drugs has frequently been highlighted. The interface between primary care, secondary care, out of hours care and social services is also important.²

In England in 2003, 650 million prescriptions were dispensed, which equates to an average of 250-350 items prescribed by a general practitioner every week, or ~13.1 prescription items/head of population (DoH).³

Drug expenditure by GPs in England accounted for approximately £4.5billion in 1998, representing about 50% of costs in primary care. This expenditure is currently rising at 9% per annum.⁴ The last five years has seen the greatest growth (27%). In 2006 GPs prescribed 981 million items at a cost of £10 billion.¹

Some of the pressures to prescribe have come from unexpected sources.The drive to meet new GP contract targets has encouraged GPs to prescribe increasing amounts of medicines and to chase patients who are 'non-compliant'.

Also, the 'pill for every ill' culture has been fuelled by the media and is now firmly embedded in the nation's psyche.

PACT (Prescribing Analysis and CosT) is a series of reports, which tells GPs what they have prescribed and how much their prescribing has cost. The data is produced by the Prescription Pricing Authority (PPA) and give information on both individual GPs’ and practices’ prescribing costs, comparing them with other doctors in the same HA and also nationally.⁴ Since January 2007, circulation of hard copies ceased and was replaced with an on-line system called ePFIP. This is available to practice users via the internet as well as via the NHS internal network.⁵

This is the use of additional professional input into one or more elements involved in the prescribing process of controlled drugs. The aim of prescribing support is to improve the pharmaceutical care of patients by allowing GP’s more time to spend with patients, for example.

• Extended formulary nurse prescribers
• Patient group direction (PGD) system⁶
• Bulk prescribing
• Prescribing in instalments: (use the FP10 MDA form e.g. drug addicts)

In the year 2000, patients over the age of 60 received 52% of all prescriptions, the majority of which were repeats.⁷ A benefit of repeat prescriptions for this age group is that they reduce patient inconvenience as well as the professional workload. A major disadvantage is the reduction of patient-doctor contact, resulting in potential clinical problems.²

When reviewing each repeat prescription, consideration should be given to the following:⁸

• Is it effective?
• Is it necessary or still required?
• Will the patient take it?
• Is the present formulation appropriate?
• Does it provide the most cost-effective treatment available?
• Has the patient had a clinical review within the last 15 months (or shorter if clinically appropriate)?

In recent years there has been a move away from compliance, which suggests an element of compulsion, to concordance, in which prescriber and patient enter into a partnership concerning the use of medication.⁹

In 2002 the National Prescribing Centre launched a Medicines Management initiative, in which concordance played a central role.¹⁰

The cornerstones of concordance include:

• The level of information given to patients
• Side effects
• The costs of medication
• The effect on lifestyle

Special clinical scenarios

Children¹¹

• Parents are mainly responsible for the administration of medicines to their children, so both the concordance of parent and child should be considered.
• Concordance in children is influenced by the formulation, taste, appearance, and ease of administration of a preparation.
• Prescribed regimens should be tailored to the child’s daily routine.
• Treatment goals should be set in collaboration with the child/parent.

The elderly⁷

Important principles include:

• Effective communication
• Keeping regimens simple
• Giving reminder charts, concordance aids and special written instructions
• Monitoring concordance by counting returned tablets or checking plasma drug levels